Systematic Review: Effectiveness of Remote Exercise Programs for Pain Reduction in Knee Osteoarthritis

Woman stretching on yoga mat at home in front of laptop, remote exercise concept

In-person exercise programs are well-established to effectively reduce pain in patients with knee osteoarthritis (OA).

Elena Losina, PhD, director of the Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center at Brigham and Women’s Hospital and co-director of the Orthopaedic and Arthritis Center for Outcomes Research, and colleagues recently explored whether the same is true of remote exercise programs. According to their systematic review published in Osteoarthritis and Cartilage Open, randomized controlled trials (RCTs) that involved an active comparator showed remote exercise programs were as effective as in-person physical therapy. Studies with an inactive comparator had mixed results.

Methods

The reviewers searched PubMed in November 2021 and Embase and MEDLINE in March 2022, using identical keywords. Their goal was to identify English-language RCTs of online, telephone, text- or app-based remote exercise programs for patients with knee OA or chronic knee pain.

RCTs incorporating other components (e.g., pain coping, self-effectiveness programs, motivational interviewing) were eligible unless a pharmaceutical intervention was used.

11 RCTs, published between January 1, 2013, and March 31, 2021, were included in the review (n=1,396). In one trial, the exercise intervention was delivered using a fully automated process, four included some contact from providers over the internet or telephone, and five included an in-person component.

Findings

The authors divide the results of the 11 trials as follows:

  • One trial published in Annals of Internal Medicine detected a significant difference in pain reduction between the intervention group and the control group that met the minimum clinically important difference (MCID). The control group received online educational material about knee OA, and the intervention group received pain-coping training and videoconferences with a physical therapist
  • In four trials, there were clinically meaningful improvements in pain from baseline within the intervention groups. All four involved interventionist-initiated follow-up over the phone, through videoconferencing and/or in person, as opposed to patient-initiated online chats or calls. Three also included behavior change counseling, either from a physical therapist or an automated program
  • In three additional trials, the interventions resulted in statistically significant reductions in pain but the improvements were not clinically meaningful (they did not reach MCID thresholds)

Continued Scrutiny Needed

The comparator groups included in these trials were quite heterogeneous, ranging from wait list controls to groups that received in-person physical therapy. There was also marked variability in outcome measures and the content of interventions. That made it impossible to perform a meta-analysis.

In a healthcare landscape increasingly turning to remote care, additional RCTs would be useful and should include standard outcome measures such as the Knee Injury and Osteoarthritis Outcome Score or the Western Ontario and McMaster Universities Arthritis Index.

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